Provider Demographics
NPI:1205975059
Name:PENNER, WILMONTE LEE (DDS, MS)
Entity type:Individual
Prefix:
First Name:WILMONTE
Middle Name:LEE
Last Name:PENNER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SAVERIEN DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-6145
Mailing Address - Country:US
Mailing Address - Phone:916-481-3213
Mailing Address - Fax:
Practice Address - Street 1:3960 EL CAMINO AVE
Practice Address - Street 2:#6
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-6534
Practice Address - Country:US
Practice Address - Phone:916-484-1133
Practice Address - Fax:916-484-1134
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics